Context and Object: Late nephrology case management for patients with chronic renal failure is consistently associated with high morbidity rate. The objectives of this study were to determine the factors associated with late nephrology case management and to describe the evolution of patients depending on the time of care nephrology. Material and Methods: It was a 5-year prospective study, observational type, going from January 1st, 2010 to December 31th, 2014. We studied all the patients hospitalized with chronic renal failure with dialysis or not and we excluded the patients hospitalized for acute renal failure. Results: The study population includes 307 men (53.4%) and 268 women (46.6%) with a sex ratio of 1.14. Age population ranged between 15 and 85 years old with a mean of 44.4 ± 16.20 years old. Their profession was distributed as follows: 220 housewives (38.3%), 181 workers (31.5%), 104 civil servants (18.1%), 56 students (9.7%) and 14 unemployed (2.4%). Patients came from all regions of the country: Conakry: 389 patients (67.6%); Lower Guinea: 82 (14.3%); Middle-Guinea: 57 (9.9%); Upper Guinea: 31 (5.4%); Guinea Forest Region: 16 (2.8%). In this study population, 48 patients were admitted in emergency (8.3%); 105 were scheduled (18.3%) and 422 were referred to the nephrology department (73.4%). Reasons for the emergency admission were acute pulmonary edema in 21 patients (43.7%), decompensated anemia in 13 patients (27.1%), loss of consciousness in 9 patients (18.7%) and malignant hypertension in 5 patients (10.4%). The reference patterns was uremic syndrome in 312 patients (54.3%), followed by high blood pressure in 247 patients (42.9%), an edematous syndrome in 234 patients (40.7%), oligoanuria in 222 patients (38.6%), morphological abnormalities on the renal ultrasound in 4 patients (0.7%). The functional symptoms were vomiting in 379 patients (65.9%), followed by dyspnea in 290 patients (50.4%), headaches in 287 patients (49.9%). Among them, 121 patients could handle alone, 431 were borne by their families and 23 were indigent; 181 patients had consulted before 1 month of the beginning of the signs, 238 between 1 and 2 months and 156 after 2 months; 48 were admitted in emergency, 105 were programmed by the Nephrology Department and 422 were referred to the other health structures of the country. Conclusion: Several factors contributed to the delay in treatment, among which: the low socioeconomic level, the delay of the reference of the patients, the long distance of the regions, the lack of Nephrology units in the country.
As well documented in the literature, the nephrologist rarely manages the medical needs of chronic renal failure patients until renal replacement therapy is required. Any unanimous and precise definition of the late reference is found in the nephrology literature neither in French nor in English. Late nephrology case management of patients with chronic renal disease is consistently associated with a more important premature mortality from 20% to 37%, from the end of the first year of dialysis, independently of the age, of the level of the residual renal function and associated co-morbidity. Patients with chronic renal failure are coming too late in nephrology (median creatinin 300 µmol/l), with a poor prognosis (7% death and 29% dialysis in 1 year) [
This study was conducted at the Nephrology Department of Donka National Hospital with a capacity of 15 inpatient beds and 12 hemodialysis stations. It includes three (3) doctors, four (4) interns and four (4) nurses. It is the only Nephrology Department of the country that is of a populated of 10,628,972 inhabitants. The country has the capital City Conakry (1,667,864 inhabitants) and 4 major natural regions: Maritime Guinea (2,640,630 inhabitants), Middle Guinea (1,727,834 inhabitants), Upper Guinea (2,929,062 inhabitants) and Forested Guinea (1,663,582 inhabitants).
This was a prospective study of observational type during a period of 5 years from January 1st, 2010 to December 31th, 2014. The study included patients admitted to the nephrology department for chronic renal failure. Were included all patients hospitalized with chronic renal failure undergoing or not dialysis and patients hospitalized for acute renal failure were excluded.
The delay in nephrology care was defined by the period between the time of onset of symptoms and the time of consulting the nephrologist.
We looked for the factors related to late nephrology care such as the consultation period, mode of admission (emergency, referred, programed) or the reference patterns and renal risk factors (arterial hypertension, tobacco, diabetes, nephrotoxic drugs, alcohol, urinary infection, obstructive uropathy).
Patients were divided into three categories: those that were able to pay their treatment, those who had support from their families and the needy.
Depending on the mode of admission, we identified patients admitted in emergency, referred by other structures and scheduled for hospitalization. The patients referred from other services were from national, prefectural and communal hospitals and the scheduled patients were those known and followed by nephrologists.
The analysis includes the description of the sample (gender, age, occupation, place of origin), determining the incidence of CKD in the nephrology department, and the description of the factors related to late nephrology care.
The data were entered with Word, Excel and analysed by Epi-info version 3.5.1 software. The results were presented through tables and figures (Tables 1-3 and Figures 1-5).Our results were expressed in percentage and some were subjected to the statistical test of Chi2 and Fisher with a threshold of meaning for any value of p = 0.05.
Region | Population | Dialysis | % patients on dialysis |
---|---|---|---|
Conakry | 1,667,864 | 389 | 67.6 |
Lower Guinea | 2,640,630 | 82 | 14.3 |
Middle Guinea | 1,727,834 | 57 | 9.9 |
Upper Guinea | 2,929,062 | 31 | 5.4 |
Forested Guinea | 1,663,582 | 16 | 2.8 |
TOTAL | 10,628,972 | 575 | 100 |
Among the dialysed population, 67.6% lived in Conakry where the only dialysis center is located; 14.3% came from the Lower Guinea more than 140 km from the center; 9.9% were from Middle Guinea over 400 km; 5.4% were originate from the Upper Guinea which is more than 650 km and 2.8% from the Forest Guinea more than 1000 km.
Nephropathy | Population | Deaths | % |
---|---|---|---|
Chronic glomerulonephritis | 201 (35%) | 39 | 19.4 |
Renal vascular | 216 (37.5%) | 37 | 17.1 |
Diabetic nephropathy | 42 (7.3%) | 8 | 19.1 |
Unknown nephropathy | 37 (6.4%) | 4 | 10.8 |
HIVAN | 33 (5.6%) | 8 | 18.7 |
Chronic interstitial nephritis | 32 (5.5%) | 4 | 12.5 |
Hereditary nephropathy | 12 (2%) | 1 | 8.3 |
Total | 575 | 101 | 17.56 |
The most frequent causes of death are the chronic glomerulonephritis (39/201); followed by renal vascular (37/216); but the vascular renal diseases are the most frequent causes of renal insufficiency (37.5%) followed by glomerulonephritis (35%). Other causes of renal insufficiency were in the order: the diabetic nephropathy (7.3%), the unknow nephropathy (6.4%), the HIVAN (5.6%), the chronic interstitial nephritis (5.5%) and the hereditary nephropathy (2%).
Associated diseases | Number | Death | P |
---|---|---|---|
HBP | 482 | 50 (10.37) | 0.0000000 |
Heart failure | 163 | 54 (33.12) | 0.0000000 |
Diabetis | 69 | 22 (31.88) | 0.0008621 |
HIV | 41 | 18 (43.90) | 0.0000042 |
Pericarditis | 26 | 12 (46.15) | 0.0000884 |
Ulcer Gastroduodenal | 26 | 11 (42.30) | 0.0006911 |
Hepatitis B and C | 13 | 4 (33.8) | 0.20 |
Tuberculosis | 9 | 5 (55.5) | 0.0025376 |
Liver Cirrhosis | 3 | 2 (66.7) | 0.025037 |
The mortality is statistically connected to the arterial high blood pressure, to the cardiac insufficiency, to the diabetes, to the HIV infection, to the pericarditis, to the gastroduodenal ulcer and to the tuberculosis.
The limitations of this study were the cost of additional tests and examinations that is not accessible to all patients; the country has only one center of hemodialysis center of 12 posts; there is no peritoneal dialysis, or kidney transplantation.
The study population consisted of 307 men (53.4%) and 268 women (46.6%) with a sex ratio of 1.14. They were all at a terminal stage of chronic renal failure. Patients were aged between 15 and 85 years with a mean of 44.4 ±
16.20 years; 6.51% were under 20 years of age; 41.7% were aged in the 40 - 59 age group; 80% were aged under 60. Their social status was as follows: 220 housewives (38.3%), 181 workers (31.5%), 104 civil servants (18.1%), 56 students (9.7%) and 14 unemployed (2.4%). Among them, 121 patients can handle alone, 431 were borne by their families and 23 were indigent. Only 9.2% had access to the hemodialysis. They came from all regions of the country. Among them, 181 patients had consulted before 1 month of the beginning of the signs, 238 between 1 and 2 months and 156 after 2 months.
The first french publications we found on issues due to delay in care, dated back to 1997 [
only in 2001 that two articles for sensitizing internists Doctors and Diabetes Doctors had been published [
Acute pulmonary edema (43.7%) had been the first reason for emergency admissions followed by decompensated anemia (27.1%). In the analysis of symptoms, the main signs shown by order of frequency was uncontrollable vomiting (65.9%); dyspnea (50.4%); headaches 49.9%; oligo-anuria (33.6%) reflecting a very advanced uremic state. Our results are slightly lower than those obtained by A.M. Ahmed in Mali who found for the same signs in the following proportions: uncontrollable vomiting 77.1%; headaches 72.1%; dyspnea 31.4%; epigastralgia 20% [
In addition to the delay in care, several other reasons could explain these morbidities such as: low socioeconomic level (causing the delay in mobilizing financial resources to pay for exams and the purchase of medicines) and associated co-morbidities.
Vascular nephropathy is the leading cause of kidney failure found in our study (37.5%) followed by other chronic glomerular nephropathies (35%). Hypertension remains the leading cause of CKD in Mali [
Late nephrology case management of chronic kidney disease was frequent in our country. This delay in treatment deprived patients from benefiting nephroprotective treatment exposing them to cardiovascular com- plications. Several phenomena have contributed to the delay in management, which include among others: the insidious nature of the disease, the lower socioeconomic level, the late reference of the patients and the lack of Nephrology unit in the regions. The reasons for the delayed transfer of patients to nephrology consultation should be corrected in each unit and nationwide for attending physicians (general practitioners, internists, cardiologists, diabetes doctors, urologists …). In return, nephrologists provide training and establish close collaboration with them for an optimal management of patients in Guinea.
There is no conflict of interest. The script I am about to present is original and represents my work and that of my co-authors. No part of the manuscript (text, table, figures) has been copied or borrowed from an existing material.
Alpha Oumar Bah,Mamadou Saliou Balde,Oury Baïllo Diallo,Oumou Kimso, (2016) Late Nephrology Case Management and Mor-bidity Due to Chronic Renal Failure, Case of Guinea. Health,08,805-812. doi: 10.4236/health.2016.89085